09-15-20 Three Large Studies: Heart Valves, Shoulders and Intubation
Drs. Lucas Bracero, Ramanjot Kang, Saamia Alam and Eric Zabirowicz
6:00 PM @ Microsoft Teams
• Makkar RR et al. Five-Year Outcomes of Transcatheter or Surgical Aortic-Valve Replacement. N Engl J Med. 2020 [PubMed]
• Joffe AM et al. Management of Difficult Tracheal Intubation: A Closed Claims Analysis. Anesthesiology. 2019 Oct;131(4):818-829 [PubMed]
• Kang RA et al. Superior Trunk Block Provides Noninferior Analgesia Compared with Interscalene Brachial Plexus Block in Arthroscopic Shoulder Surgery. Anesthesiology. 2019 Dec;131(6):1316-1326 [PubMed]
Dr. Bracero reviewed regional blocks and presented the Kang et al article. Superior trunk block was compared with interscalene brachial plexus block for 80 patients undergoing arthroscopic shoulder surgery. They found no significant differences in pain score 24 hours after surgery. However, the superior trunk block resulted in significantly less hemidiagphragmatic paresis (76.3% vs 97.5%).
Dr. Alam gave a concise presentation about the Makkar et al article. This randomized control trial compared 2032 patients assigned to either transcatheter or surgical aortic-valve replacement in terms of death or stroked within 5 years. Moreover, they compared transfemoral vs transthoracic access. They found no significant differences between the TAVR and surgical approaches. However, incidence of death or disabling stroke was higher after TAVR than after surgery in the transthoracic-access cohort. In the discussion, it was noted that TAVR has changed how we treat cardiac care patients. Now the majority of our cases are TAVR.
The final article of the evening (Joffe et al) was about failed intubation and is an important one for our specialty. It was presented by Dr. Kang. This closed claim analysis compared 102 claims during 2000 to 2012 with 93 claims during 1993 to 1999. Although there was a higher proportion of death in the more recent claims, the more recent patients were sicker and had more emergency procedures. There was also an increase in the number of claims for non-operative settings. We discussed the importance of good judgement, having a secondary plan and asking for help during a difficult tracheal intubation.
Drs. Figueroa, Mathew and Kim
6:00 PM @ Microsoft Teams
• Khanna AK et al. Prediction of Opioid-Induced Respiratory Depression on Inpatient Wards Using Continuous Capnography and Oximetry: An International Prospective, Observational Trial. Anesth Analg. 2020 Oct;131(4):1012-1024. [PubMed]
• Schwenk ES et al. Mepivacaine versus Bupivacaine Spinal Anesthesia for Early Postoperative Ambulation. Anesthesiology. 2020 Oct 1;133(4):801-811. [PubMed]
• Jang Y-E et al. Subcutaneous Nitroglycerin for Radial Arterial Catheterization in Pediatric Patients. Anesthesiology. 2020 Jul;133(1):53-63. [PubMed]
Dr Mathew gave a terrific review of the Schwenk et al report of a randomized controlled trial of patients undergoing primary total hip arthroplasty. The authors found that patients given mepivacaine ambulated sooner (p < 0.001) and were more likely to be discharged the same day (p < 0.014) in comparison to patients given hyperbaric or isobaric bupivacaine. There was some discussion regarding how the n number was obtained.
Dr. Figueroa gave a concise review of the article by Jang et al. It was really interesting to hear about the potential use of nitroglycerin in pediatric patients. The study concluded that subcutaneous nitroglycerin injection before radial artery cannulation improved the first attempt success rate (91.2% vs. 66.1%, p<0.002). There was also a decrease in the complication rates in patients given ntg.
Dr. B Kim gave a thorough review of the Khanna et al observational trial on opioid-induced respiratory depression. The study concluded that the PRODIGY Score could enable prediction of respiratory depression in patients receiving opioids on the general care floor. Dr Bergese noted that the PRODIGY study has found that these events occur primarily either in the late afternoon or late in the evening. This will be published in a forthcoming study.
02-23-21 Two recent RCTs
Drs. Shuaib, Watson, Zabirowicz
6:00 PM @ Teams
• Li et al. Intravenous versus Volatile Anesthetic Effects on Postoperative Cognition in Elderly Patients Undergoing Laparoscopic Abdominal Surgery. Anesthesiology . 2021 Mar 1;134(3):381-394 [PubMed]
• Karaaslan et al. A comparison of laryngeal mask airway- supreme and endotracheal tube use with respect to airway protection in patients undergoing septoplasty: a randomized, single-blind, controlled clinical trial. BMC Anesthesiol. 2021 Jan 7;21(1):5 [PubMed]
Dr. Shuaib gave a terrific review of the article by Karaaslan et al. It was really interesting to hear about all the findings that LMA-S provided more effective airway protection than ETT in preventing blood leakage in septoplasty procedures. A comparison of LMA vs ETT was discussed . There was consensus that LMA positive pressure ventilation is avoided and that spontaneous ventilation with an LMA is safest.
Dr. Watson gave a fabulous review of the article by Y. Li et al. The authors considered cognitive disorders at postoperative day 5-7 with patients undergoing propofol anesthesia vs a SevoFlurane based anesthetic. They found no differences between the groups. However, high levels of blood interleukin-6 after surgical incision may be an independent risk factor for delayed cognitive recovery.
03-23-21 Two RCTs Looking at Opioids
Drs. Kant, Xiao
6:00 PM @ Teams
• Carella et al. Influence of Levobupivacaine Regional Scalp Block on Hemodynamic Stability, Intra- and Postoperative Opioid Consumption in Supratentorial Craniotomies: A Randomized Controlled Trial. Anesth Analg. 2021 Feb 1;132(2):500-511.PubMed
• Murphy et al. Clinical Effectiveness and Safety of Intraoperative Methadone in Patients Undergoing Posterior Spinal Fusion Surgery: A Randomized, Double-blinded, Controlled Trial. Anesthesiology. 2017 May;126(5):822-833. PubMed
Dr. Kant gave a terrific review on the Murphy et al paper. It was really interesting to hear about intraoperative methadone use for reduction of postoperative opioid requirements. Because patients showed improved pain scores and improved satisfaction it will be interesting to see if there will be increased use of this. During the discussion it was noted that methadone is not used frequently but that it actually works very well.
Dr. Xiao summarized the article by Carella et al well. This article evaluated the influence of regional scalp block on hemodynamic stability during the noxious stimulus of skull pin fixation, skin incision, bone incision and dura Mater incision as well as its influence on intraoperative anesthetic agent consumption. The authors found that the block did provide adequate and prolonged postoperative pain control as compared to placebo. It was discussed that it’s always good to see differing ways of care. As to its use at SB -that is something for future discussion with the neurosurgeons.
05-25-21 Looking at the Airway
Drs. Sarah Lee and Grace Lin
6:00 PM @ Teams
• Bridwell et al. Diagnosis and management of Ludwig's angina: An evidence-based review. Am J Emerg Med. 2021 Mar;41:1-5. [PubMed]
• Tong & Tung. A Randomized Trial Comparing the Effect of Fiberoptic Selection and Guidance Versus Random Selection, Blind Insertion, and Direct Laryngoscopy, on the Incidence and Severity of Epistaxis After Nasotracheal Intubation. Anesth Analg. 2018 Aug;127(2):485-489. [PubMed]
Dr. Lee presented a terrific review of the Tong & paper. The visualization of the anatomy was very helpful. The study found that nasal fiber optic endoscopy identified asymptomatic nasal pathology in 51 % patients. Bleeding was greater when using the blind tube insertion /direct laryngoscopy. The fiberoptic approach was found to reduce the severity of epistaxis. During the discussion it was noted that pediatric population was not studied, so this technique should not be used in Peds patients. In addition, tubes were thermosoftened at 37°C whereas we typically use 40°C. It was also supposed that fiberoptic is not usually performed so it is hard to know whether bleeding results from this. Also important to realize that it takes time to perform this technique.
Dr. Lin summarized the Bridwell et al. paper. This article brings awareness to Ludwig's angina, a life threatening condition. It is du to a rapidly spreading infection that is more common in immunosuppressive disease and in those with poor dentition. A woody or indurated floor of the mouth can occur with a double tongue look as well as submandibular swelling and trismus later. The air was can be rapidly compromised. Flexible intubation endoscopy is the first approach. ICU is necessary for airway observation as well as broad spectrum antibiotics and surgical source control. Those who have seen this condition mentioned that drying agents such as glyco and diphenhydramine are helpful. No sedation is given and these are done awake with topicalization. Afterward there is an ICU stay followed up by extubation with head up. A leak test must be done.
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